Amendment 164

Health and Care Bill - Committee (6th Day) (Continued) – in the House of Lords at 4:00 pm on 26th January 2022.

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Baroness Wheeler:

Moved by Baroness Wheeler

164: Clause 26, page 37, line 35, at end insert—“(4A) The indicators of quality set by the Commission under subsection (4) must include—(a) whether national standards in the care of people with rare and less common conditions are being met;(b) whether the views of patients with rare and less common conditions are being represented;(c) whether people with rare and less common conditions have access to a named clinical nurse specialist.”Member’s explanatory statementThis amendment would require integrated care boards to be assessed by the Care Quality Commission on the provision of care for people with rare and less common conditions, in particular.

Photo of Baroness Wheeler Baroness Wheeler Shadow Spokesperson (Health and Social Care), Opposition Deputy Chief Whip (Lords), Shadow Spokesperson (Levelling Up, Housing, Communities and Local Government)

My Lords, Amendment 164 heads this wide-ranging group and probes how the proposed Care Quality Commission rating system for ICBs’ work in practice, with a particular focus on rare and less common conditions, although this debate is more broadly relevant to all aspects of the CQC’s role.

Amendments 178 and 240 from the noble Lord, Lord Sharkey, to which I have added my name, also relate to people with rare diseases and their access to innovative medicines and medicinal products, and the general need for awareness-raising about those conditions among health and social care staff. I remind the Committee of my role as vice-chair of the Specialised Healthcare Alliance. The noble Lord will speak to those amendments later.

The group also covers amendments on wider care and safety issues that impact on patients, including ensuring that liothyronine T3 is available to patients when it is prescribed by a doctor and the regulation of healthcare and associated professions. This includes safeguards to apply under the Secretary of State’s power to alter the professional regulatory framework; protecting the use of the title “nurse”; hospital food standards for patients and training for staff; reviewing the surgical consultants’ appointment process; and licensing aesthetic non-surgical cosmetic procedures in registering cosmetic surgery practitioners.

The noble Lords who have their names to these amendments will speak to them, so I will leave them to it and concentrate on my rare disease issues and the matters that our Front Bench team have added their names to. Returning to the CQC, and following on from the previous debate on Clause 26, on the amendment tabled by the noble Lord, Lord Lansley, regarding the role of the Secretary of State in setting objectives and priorities, overall, we welcome the extension of the CQC’s remit to ICBs but now need to understand how it will work in practice.

As it stands, the Bill establishes an overarching framework under which the CQC will need to determine for itself the quality indicators against which it will assess ICBs. My amendment raises the issues about the quality indicators relevant to those with rare and less common conditions. If the purpose of the rating system is to protect patients, it must help to ensure that national standards of patient care, where they exist, are being met. Under the NHS’s plans to jointly commission or delegate commissioning responsibility for specialised services to ICBs, set out in NHS England’s Integrating Care paper, an important assurance given is that specialised services will

“continue to be subject to consistent national service specifications and evidence-based policies determining treatment eligibility.”

Will the CQC ensure that services organised by ICBs are organised in line with these national specifications?

Moreover, people with rare diseases are concerned that if services are to be commissioned in some way by ICBs in future, rather than just NHS England, their voices may be lost. NHS England’s specialised commissioning team meets regularly with representatives of the rare disease community, including the SHCA, and it is important that ICBs can hear their views too. How will this happen and how will the CQC rating system act to ensure that this happens?

Finally, one of the key asks of patients with rare diseases to help deliver continuity in their care is that they have access to a named clinical nurse specialist, which is commonplace for patients with more common conditions. That continuity of care is an important marker of quality. Will the CQC rating system help to deliver it?

Beyond these questions are broader ones. If the bulk of the CQCs work will continue to focus on inspecting providers, can the Minister explain how it will ensure that its ICB ratings are not unnecessarily duplicative, given that providers will form part of ICBs? Also, the CQC looks at whether services are safe, effective, caring, responsive and well led. Given that the first three of these should continue to be the primary concern of those providing care, rather than of the ICBs organising it, how will the CQC ensure that the new rating system clarifies rather than dilutes this accountability? How will the CQC’s work align with the wider performance management of ICBs undertaken by NHS England? How specialised services will operate is a complex area and I am happy for the Minister to write to me on some of the specifics of my questions.

As I said, I will speak briefly to other amendments in this group, to which Labour Front-Benchers have added their names. Amendment 243, tabled by my noble friend Lady Merron, covers the important issue of the protection of the title “nurse”, and is supported by three respected medical and healthcare professionals whose contributions I look forward to. The recent Health Service Journal survey found hundreds of roles that do not require Nursing and Midwifery Council registration but use “nurse” in the job title. While “registered nurse” is a title protected by the NMC, “nurse” is not. The term may be used by anyone in the UK to offer professional advice and services, and people with no nursing qualifications or experience, or who have been struck off the professional register, may use it.

Obviously, this is worrying and even dangerous—a dangerous trend which potentially compromises patients’ health. What progress is being made on the Government’s review of healthcare professional regulation following their consultation last year? Surely we must follow the example of other countries, such as France and Australia, in giving the consistently most trusted profession in the UK the recognition and protection that it deserves.

My noble friend Lady Thornton has added her name to Amendment 258, from my noble friend Lord Hunt, to the welcome new Clause 145, on hospital food standards. It underlines the importance of investment in the food served to patients in hospital and other care and treatment settings. It is welcome because it specifies food quality and standards and stresses the importance of recognising staff skills, experience and training, as well as ensuring investment in NHS kitchens and catering equipment to ensure that the highest standards can be maintained.

On Amendment 266 from my noble friend Lady Merron, we seek to give the Secretary of State power to introduce a licensing regime for aesthetic non-surgical cosmetic procedures and to introduce an offence of practising without a licence. This area is crying out for regulation. The Department of Health’s own report has said that non-surgical interventions which can have major and irreversible adverse impacts on health and well-being are almost entirely unregulated. We fully recognise that this is also a highly complex policy area. However, I understand that noble Lords concerned about this issue had constructive and positive discussions yesterday with the Minister, and I look forward to the Minister updating the House on the scope and discussions of the Government’s ambition in this important area.

Finally, I offer my strong support for my noble friend Lord Hunt’s Amendment 176, which seeks to ensure that the general powers of the Secretary of State to direct the functions of NHS England include ensuring that when T3 is prescribed to patients with hyperthyroidism, the drug is made available to them. My noble friend rightly raises this issue at every opportunity, and I hope the Minister will have a bit of good news for him today and tell us that some real progress has been made. It is clear that many thyroid patients would benefit hugely from the declassification of T3 as a high-cost drug, back to a drug that is routinely prescribed in primary care. It is much cheaper now, and the many patients who were taken off the drug and continue to be denied it need to have it restored. The Government must ensure that the now updated NICE guidelines which reflect this new position are implemented consistently across the new NHS structures, rather than repeat the record of the nearly 50% of CCGs which failed to ensure that the drug is properly prescribed.

I will leave it at that, and I look forward to the debate.

Photo of Baroness McIntosh of Hudnall Baroness McIntosh of Hudnall Deputy Chairman of Committees, Deputy Speaker (Lords)

I remind the Committee that both the noble Baronesses, Lady Brinton and Lady Masham, will be contributing remotely. I call the noble Baroness, Lady Brinton.

Photo of Baroness Brinton Baroness Brinton Liberal Democrat Lords Spokesperson (Health)

My Lords, I have signed two amendments in this very wide-ranging group. The first, in the name of the noble Lord, Lord Hunt, is Amendment 264 on the appointment of surgical consultants. As the noble Baroness, Lady Finlay of Llandaff, said in your Lordships’ House recently, 48% of advertised consultant posts last year went unfilled. Given our discussions about the workforce earlier this week, we need as many posts filled as possible and to remove any bureaucratic barriers to so doing.

Part of the problem at the moment is that trusts are having difficulties establishing appointment panels which can make these consultant appointments. Currently, the rules are too tightly drawn in the National Health Service (Appointment of Consultants) Regulations 1996 and the subsequent 2005 guidance. The members of all the royal colleges across the UK have a wealth of expertise, but the current legislation says that only members of English royal colleges can help trusts fill their appointment duties. In its helpful briefing, the Royal College of Surgeons says that the Royal College of Emergency Medicine, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Physicians of Edinburgh are excluded from being eligible to join these panels. This amendment would be a simple remedy and speed up the appointment of much-needed consultants, and I do hope that the Minister can agree to it.

I have also signed Amendment 266 in the name of the noble Baroness, Lady Merron, on the urgent need to ensure that practitioners undertaking non-surgical aesthetic procedures such as lip fillers, injectables, thread lifts, semi-permanent make-up, laser treatments, piercings and tattoos are properly trained and licensed. These treatments are easily available to members of the public, but without the safeguards required when being carried out in the health sector. I am afraid that we see daily in the press and media reports on the many problems when treatments go wrong, which can include infection, disfiguration and burns, among other serious issues. When treatments do go wrong, it is usually the NHS that has to pick up the pieces, so I believe it is very much in the interests of the Department of Health and Social Care to accept this amendment.

The signatories to this amendment have been working with the Chartered Institute of Environmental Health, alongside a coalition of public health organisations and industry representatives, so that we can make sure that a licensing scheme can be introduced for all non-surgical aesthetic procedures. This will enable the setting of appropriate standards, a level playing field for practitioners and, importantly, protect consumers in this sector.

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench

My Lords, I shall speak to Amendments 178, 266 and 293. Amendment 178, which was tabled by the noble Lord, Lord Sharkey, is important for people with rare and less common diseases. The amendments could be a lifeline for people who have rare conditions who use products that may be the only substances that work. There is an enormous selection of rare conditions. It can be a desperate situation when some medicines are developed but take a long time to be given the all-clear by NICE. Some medicines are not available in England on the National Health Service but are available in other countries, sometimes even in Scotland. That is devastating and frustrating.

I support Amendments 266 and 293, on the cosmetic surgery industry, which must be made safer. It is extraordinary that this business is only partially registered. Many people who have such a procedure take for granted that the practitioner will be registered and fully insured. There have been some disastrous results when things go wrong with a beauty procedure. I know of some plastic surgeons who work only in the National Health Service, as they do not want to be tarred with the same brush as uninsured cowboys. Amendments 266 and 293 deal with a wide selection of cosmetic procedures, some of which are psychologically important to many people. There is wide interest in making this trade safe and getting it registered. I hope the Minister realises that this is an important matter that needs putting right.

Photo of Lord Hunt of Kings Heath Lord Hunt of Kings Heath Labour

My Lords, I have Amendment 176, the second amendment in this group, and two other amendments. I shall start with Amendment 176 which is concerned with the treatment of thyroid patients who continue to be denied liothyronine, otherwise known as T3, as the most appropriate treatment for them. For some patients, the standard treatment is not effective. T3 has proven to be a much better treatment, but tragically, a few years ago the manufacturers grossly inflated the cost of T3 by a massive 6,000%. Understandably, NHS England and its associated prescribing advising machinery strongly discouraged the use of the drug and, as a result, many patients had T3 withdrawn and suffered quite considerably or had to fund it privately or source it from abroad. Happily, the price of T3 has come down by 75%, although it could go down further, but I believe it is no longer categorised as a high-cost drug.

The problem is that clinical commissioning groups still treat it as a high-cost drug, so the situation is still very difficult for patients who need it—those for whom the standard treatment is not appropriate. The current guidance states that T3 can be prescribed to patients who have unresolved symptoms on the standard treatment if it is initiated or confirmed following a review by an NHS consultant endocrinologist. A statement in July 2021 restated NHSE guidance, but it has not been followed by clinical commissioning groups. A survey done recently by UK thyroid charities, to which I pay huge tribute, says that 44% of CCGs have not fully adopted the national guidelines or are wrongly interpreting them.

What are we to do? What is the situation here, where we have clear guidance that is not being followed? This goes back to our previous debates about the various mechanisms being brought in to ration treatments, against national guidance or technology appraisal advice from NICE. It is the same issue. I am not expecting the Minister to issue a direction but I am expecting him to tell CCGs and, in future, integrated care boards to get off their backsides, start implementing the guidance properly and realise that this is no longer such a high-cost drug. I appeal to him to do something about that.

I also hope that the Minister will do something about hospital catering. I confess to your Lordships that I am president of the Hospital Caterers Association, where I work very closely with some great professional staff who have to work with their hands tied behind their back. Often they do not have the resources to provide the high-quality food that everyone wants and expects.

During Covid we saw in many local NHS facilities a determination to do everything possible to improve nutrition for both patients and staff. Miraculously, hot food was made available to staff overnight, which, as noble Lords know, seems to have been beyond the capacity of the NHS for many years. I do not know why I am looking at the former Chief Nursing Officer as I say this; I think it is an appeal for support.

This clause is highly welcome as I believe it will lead to higher standards, but my amendments would enable the caterers to deliver on them. The first key point is this: they need the resources to be able to do it. The amount of money spent on hospital food per day at the moment is simply not sufficient. Secondly, we need more training for staff. The training programmes have disappeared, and we need to get them back in to give staff the opportunity to show what they can do. Thirdly, we need to make sure that NHS trusts and foundation trusts are fully on board with bringing forward these regulations. There is no doubt that the efficiency programmes have taken their toll on the budgets for hospital catering and that, equally, the old-style national training schemes fell away and have not been replaced. The pay grade of qualified chefs and cooks needs to be reviewed to reflect the importance of their role. This issue is important in terms of the standards of food and nutrition for our patients and for the well-being of our staff.

My final amendment in this group is Amendment 264. What links all these amendments is that we need more consultants appointed—a small effort to enable us to improve the efficiency of the system. I remind the Committee of my GMC connections in relation to this. The amendment would add the Royal College of Surgeons of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow, and their associated dental faculties, to the colleges that may be involved in the appointment of NHS consultants. My amendment was inspired by the Royal College of Surgeons of Edinburgh, which noble Lords might be surprised to learn has an office in Birmingham because many consultants who work in the English NHS are members of the Scottish colleges.

There seems to be a lacuna in the current regulations. According to the National Health Service (Appointment of Consultants) Regulations 1996 and subsequent guidance issued by the department in 2005, only the Royal College of Surgeons in England is permitted to review surgical consultant job descriptions and send a royal college representative to the advisory appointment committees when it comes to the appointment of consultant surgeons. Other elements of my amendment apply to the appointment of physician clinicians, and the Royal College of Physicians of Edinburgh and the Royal College of Emergency Medicine are also supportive. Although the process and guidance apply only to NHS trusts, foundation trusts are encouraged to follow it.

The Minister has yet to accept any amendment to the Bill. The usual line from the Government is, “We will do this when legislation is available to do so.” Here is a great opportunity for the Minister, as we are here on day 6 of Committee, to get up and say that he is going to accept my amendment.

Photo of Baroness Barker Baroness Barker Liberal Democrat Lords Spokesperson (Voluntary Sector), Deputy Chairman of Committees

My Lords, in following the noble Lord, Lord Hunt, I declare an interest as the patron of the National Association of Care Catering, a position that I took over from the noble Baroness, Lady Greengross. I admit that, when I had this great honour thrust upon me, I had little idea what I was getting into—and I have discovered a world of highly dedicated, professional people whose contribution to the health of the nation is very much overlooked. I managed to attend their national conference in Nottingham last October, and I have to say that it was one of the most harrowing afternoons I have spent, as they talked about what they had gone through as the people who supply catering not only in hospitals and acute hospitals but in care homes, as well as doing meals on wheels.

I will pick up one point that the noble Lord, Lord Hunt, made, on training. He is absolutely right that this area has suffered a great deal because of various changes not just to training in the NHS but to the training in higher education. We do not have a recognised qualification in care catering in this country, yet these are people who have to produce food for people who have dysphagia, multiple food intolerances and dementia, people who quite often are suffering from malnutrition when they come into hospital, and people who have allergies and often suffer from dehydration. The people who have worked in this field, and some of them have worked in it for many years, suffer a deep sense of frustration, which is that when young people in school or college show an aptitude for or a willingness to go into the world of catering, they are directed towards restaurant catering, because that is where the teachers and lecturers think the money is to be made. Actually, catering for people with difficult medical conditions is a lot more complicated.

I say to the Minister that I am also really impressed by the specialist companies that work in this field—those that produce specialist menus and enable people to order ingredients for complicated menus in complicated settings, as well as those that manufacture cutlery and crockery and vessels that can be used by people whose interaction with that sort of thing is hampered. These can bring a dignity and focus to something that is much overlooked—but talk to dieticians and you will increasingly understand the importance that food plays in maintenance of health and recovery.

I do not know whether or not this will make it into the Bill, but will the Minister go back to the department and ask whether his officials might meet some of the people who do a remarkable and much overlooked job, day in, day out, and who these last two years, perhaps more than anybody else in the NHS, deserved the clap, if only people knew what they had done?

Photo of Baroness Fraser of Craigmaddie Baroness Fraser of Craigmaddie Conservative 4:30 pm, 26th January 2022

My Lords, in this rather large group of amendments, I shall take us from catering to my Amendment 242 on professional regulation. I thank the noble Baroness, Lady Finlay, for adding her name. I draw your Lordships’ attention to my registered interests, in particular as chief executive of Cerebral Palsy Scotland. I am involved with the employment of regulated allied health professionals.

Clause 142 gives the Secretary of State far-ranging powers to alter the professional regulatory landscape, with the potential to make significant changes to how certain health and care professions may be regulated, including the power to remove professions from, or bring professions into, statutory regulation.

The UK model of regulation for healthcare is rigid, complex and needs to change to better protect patients, to support our health services and to help the future workforce meet future challenges. The case for reform has been acknowledged.

Whether a health and care profession falls under regulation is a major decision affecting not only the professions themselves but employers, patients and service users who place their trust in those professionals. My Amendment 242 is a probing one. I want to explore some of the issues that will be particularly important for the Government to consider as and when they might seek to use these extended powers.

I want first to thank my noble friend the Minister and the Bill team for the time they have taken so far to discuss the issues around my amendment. We are all agreed on the importance of encouraging greater collaboration between regulators, with the ability to share data and intelligence, but I remain to be convinced that the legislation is being used to reduce regulatory silos, which is crucial to reducing regulatory failures in the future.

I want to be clear that I am not advocating for a single super regulator, which would be a step in the wrong direction, not to mention complicated, disruptive and expensive. I would rather harness the best elements of professional regulation and give the regulators the tools to work more closely together and share best practice more consistently.

I accept that work is being done in the department on various regulatory reform initiatives. These are all important, but it strikes me that they are all focused on individual regulators and amend specific operational issues, rather than looking at the landscape as a whole and what could be achieved.

We have sadly seen all too many reviews and inquiries which have identified regulatory silos as a key factor in why something went terribly wrong. My noble friend Lady Cumberlege’s First Do No Harm report highlights the issue starkly, but the Paterson inquiry, the Sir Robert Francis report on Mid Staffs, the Shipman inquiry and others have all underscored the value of greater collaboration between regulatory bodies, sharing data and intelligence as well as adopting shared professional standards. Reducing and removing silos is also good for professionals and employers, with benefits in terms of intra-professional learning and for professional and patient safety.

I am grateful to the Health and Care Professions Council for its briefing, but I was concerned to note something which regulators have stressed to me: that due to their tightly defined duties, they have often been forced to resort to informal memorandums of understanding to try to make the system work better. That is piecemeal and inefficient— frankly, I would be extremely disappointed if the Minister in his response was to rely on such MoUs to fix the issue.

Do not the powers in this Bill offer a chance to look at things differently: a whole system regulatory approach rather than a set of silos? Amendment 242 identifies some principles and considerations that I believe the Government would find beneficial in developing this more collaborative landscape.

Maintaining regulatory independence is crucial. The Government have rightly recognised this in other legislation recently, but I would welcome confirmation from the Minister that this remains a cornerstone of any future regulatory reform proposals. I would be grateful for reassurance that no regulatory reform would be undertaken by the UK Government without working with the devolved Administrations to ensure that it worked for all parts of the UK.

I particularly want to highlight the benefits of multi-profession regulation, which, as the CEO of an organisation that relies on a range of expert allied health and care professionals registered with the HCPC, I see at first hand, supporting improvements across professions that are increasingly interconnected. As the Minister is aware, the HCPC regulates 15 professions, so is able to utilise common frameworks and outcome-based standards. This approach could, and should, be spread among all the professional regulators.

This is particularly important as the Government, NHS England and NHS Improvement seek to create a more flexible workforce with an ability to move between professions, work as multidisciplinary teams and support career progression. From my own experience, I know that this is positive, but we need our regulatory system to keep up with innovations in delivery. Can my noble friend the Minister therefore tell us about how we can harness the benefits of multi-profession regulation and how he anticipates this will influence the Government’s thinking in terms of reform? Collaboration and the development of a system-wide approach to overcome fragmentation and silos is critical to the future success of regulation. It is an enabler of better care, and a collaborative structure would generate considerably higher and richer levels of data.

Finally, this holistic approach would offer an opportunity to create consistent criteria for making decisions about which professions may be brought into or taken out of regulation. Could the Minister put it on record today that the issues in the amendment are principles that would govern the future use of the powers within Clause 142, that they are all principles that the Government are actively considering and that no decisions on regulatory change would be taken if the criteria set out in this amendment were not met? Once again, I thank him and his team for his engagement so far, and I look forward to his response today. I hope we can continue discussions between now and Report.

Photo of Lord Patel Lord Patel Crossbench

My Lords, I rise to speak to Amendment 243 in the name of the noble Baroness, Lady Merron, and Amendment 264 in the name of the noble Lord, Lord Hunt of Kings Heath.

Yesterday I was chastised—wrongly, in my view—for speaking at length. Such boldness requires training in speaking up, confidence in being right and using authority. The comments came from a government Whip, who happens to be a registered nurse. As a doctor, I am used to that. When a nurse speaks up, patient safety improves, health equity improves, collegial relationships are stronger—again, as a doctor I can vouch for that—and healthcare systems improve. This is because of their training. Not recognising legally the status that the title of “nurse” brings to those that are highly trained and qualified and on a nursing council register is wrong.

We all know what a nurse is; a nurse is highly trained, highly competent, can do the job well and is on a nursing register. Anybody else is not a nurse. It is right, therefore, that we recognise this and give it a legal status. Furthermore, the NHS and health providers should not employ anyone as a nurse who does not meet the above criteria. I understand that last year there were 195 advertisements for nurses in the NHS which did not say that the qualification of being registered was necessary. In my view, that is wrong. I strongly back this amendment, and I look forward to the contribution of my noble friend Lady Watkins.

Turning to Amendment 264 on the appointment of consultants in surgery, I am a fellow of the Royal College of Surgeons of England, the Royal College of Surgeons of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow, so I speak on behalf of all surgical colleges. Let me give your Lordships an example: there is a surgical post empty in Birmingham. A highly qualified person, who was well-trained in Scotland and holds a fellowship of the Royal College of Surgeons of Edinburgh, is a key candidate for application but cannot be appointed because the Royal College of Surgeons of England cannot provide an assessor. On the other hand, there is a surgical vacancy in Glasgow, and the top candidate is a fellow of the Royal College of Surgeons of England but can be appointed without a Royal College of Surgeons of England assessor being there. That is a total anomaly.

A person can be appointed who is fully trained in Scotland, is a fellow of the Royal College of Surgeons of Edinburgh, works in Cambridge, applies in Cambridge, but you cannot have an assessor from the Royal College of Surgeons of Edinburgh. In all other specialties—the Royal Colleges of Obstetricians and Gynaecologists, of Ophthalmologists, of Radiologists, of Psychiatrists, of Anaesthetists, and in public health—the assessor can come from any part of the United Kingdom. This anomaly can be stopped very easily. I agree with the noble Lord, Lord Hunt of Kings Heath, that it is not a big deal; just change it in legislation. I do not know who opposes it.

Photo of Baroness Watkins of Tavistock Baroness Watkins of Tavistock Deputy Chairman of Committees

My Lords, it is a pleasure to follow the noble Lord, Lord Patel, on the term “nurse”, which is protected in law at the moment only for those who are a “registered nurse”. This means that anyone can describe themselves as a nurse, as the noble Baroness, Lady Wheeler, outlined. They can even describe themselves as a nurse if they have no qualifications or experience—or, perhaps more seriously, have just been struck off the register. As somebody who was a member of the forerunner to the Nursing and Midwifery Council, I can say that we do not strike people off the register lightly, so the risks of such people being at large and describing themselves as nurses are serious. For this reason, a petition was created calling for the title “nurse” to be protected further in UK law.

In the initial response by the Government to the petition, recognition was given that the protection of professional titles

“provides assurance to the public that someone using that title is competent and safe to practise.”

The response references a consultation by the Department of Health and Social Care on professional regulation, Regulating Healthcare Professionals, Protecting the Public. In the Nursing and Midwifery Council response to this consultation, the nursing regulator recognised issues around the limitations of “nurse” not being a protected title and said it did not think that its current powers are sufficient,

“given that they are primarily based around titles that are not widely understood by the public or used by the professions.”

This amendment is designed to ensure that there are sufficient regulatory levers to be able to protect the public in the future.

Nurses on the NMC register find it difficult to understand why the Government are reluctant to protect the title. As part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the clinical commissioning group governing body. In Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, the CCG governing body is required to include at least one registered nurse within its membership. This created a statutory commissioning role for nursing leaders in England that will be lost should this not be required within integrated care boards’ executive membership. Please can the Minister explain whether guidance will include a recommendation that there should be a registered nurse as part of the executive team on integrated care boards?

Photo of Lord Kakkar Lord Kakkar Crossbench

My Lords, I support Amendment 264, in the name of the noble Lord, Lord Hunt of Kings Heath, to which I have added my name. In so doing, I remind noble Lords of my own interests, particularly as a fellow of the Royal College of Surgeons of England, a fellow of the Royal College of Physicians of London and an honorary fellow of the Royal College of Surgeons of Edinburgh.

This is a critical amendment, as the noble Lord, Lord Hunt of Kings Heath, indicated, strongly supported by my noble friend Lord Patel. Currently, the National Health Service (Appointment of Consultants) Regulations 1996, with additional guidance provided by the department in 2005, restricts membership of advisory appointments committees for consultants to certain royal colleges, as we have heard with the appointment of surgeons by the Royal College of Surgeons of England alone—and, indeed, for physicians by the Royal College of Physicians of London. This is an anomaly. The medical royal colleges across the United Kingdom are recognised in terms of the postgraduate training that they are able to supervise, the continuing professional development they are able to provide and, indeed, collaborate with regard to postgraduate examination which is required for provision of the certificate for the completion of specialist training. However, when it comes to the question of consultant appointment, there is this restriction.

Noble Lords might ask why it is important that this matter be dealt with. The provision by a medical royal college of a professional member to serve as part of the appointment process for a new consultant is critical. Those representatives provide expertise and insight with regard to the nature of the job description, the requirements for the individual post, and the assessment of individual candidates as part of the selection process on the day.

The regulations apply only to non-foundation trusts, but guidance provided in 2005 recommends that NHS foundation trusts follow exactly the same process and involve representatives on these advisory appointments committees. In addition, the Academy of Medical Royal Colleges has strongly encouraged that all consultant appointments follow these regulations and guidance. This means that, when it comes to the question of consultant appointment, only representatives nominated by the Royal College of Surgeons of England can serve.

This is creating a bottleneck in terms of appointment of consultants, and this is happening at a critical moment, when the NHS must look to make more and more consultant appointments to meet the increasing demands we are seeing—particularly with regard to long elective waiting lists—that attend surgical specialties and subspecialties in particular.

It is possible that NHS foundation trusts might take the view that this bureaucratic hurdle to finding members for advisory appointments committees from the royal colleges could easily be overcome by ignoring the guidance. Then, we would lose this critical element of expert professional input into the appointment of future consultants. That would really be a very unfortunate situation.

As we have heard from the noble Lords, Lord Hunt of Kings Heath and Lord Patel, this is a very easy issue to address. There is no objection, and it would send a very powerful signal, with regard not only to the importance of professional participation in the appointment of future consultants but to the recognition that, although health is a devolved matter, we recognise the United Kingdom as a single entity in so many questions for the provision of health and, in particular, the training and development of healthcare professionals and their ability to work across our entire country.

Photo of Lord Lansley Lord Lansley Conservative 4:45 pm, 26th January 2022

My Lords, can I just take us back to Amendment 266, to which I have added my name, before we lose sight of it? It was helpfully introduced by the noble Baroness, Lady Wheeler, and its purposes were explained very well by the noble Baroness, Lady Brinton.

I just want to add a bit of context, which I hope will commend itself in particular to my noble friend Lord Howe on the Front Bench, in that he and I tackled together the PIP breast implant problems that emerged in December 2010 and which led directly, subsequently, to us asking the distinguished first medical director of NHS England, Bruce Keogh, to undertake an inquiry. Since the report of that inquiry, we have made considerable progress. Most recently, noble Lords will recall that the noble Baroness, Lady Wyld, took through the Private Member’s Bill from Laura Trott in the other place to assist in the regulation of Botox treatment for under-18s.

The point is that there is still unfinished business. Amendment 266 relates to giving the Secretary of State the power to set up a licensing process for non-surgical cosmetic procedures—not through the CQC in this case, because the CQC regulates healthcare professionals, but almost certainly through the mechanism of asking local authorities to undertake a licensing process. It gives the Secretary of State all the flexibility that we have grown accustomed to legislation having to give them, but it does so in a way that enables the regulation that would be brought in using this power to be proportionate, being very clear that it should apply only to those activities that present a significant risk. It makes sure that it takes advantage, for example, of the national standards that have been put in place by the Joint Council for Cosmetic Practitioners. It would be very helpful in trying to mitigate the risks associated with non-surgical cosmetic procedures.

Amendment 293 in my name is a follow-up to a Private Member’s Bill that made no progress. It again follows Bruce Keogh’s report and looks to give the General Medical Council the legislative opportunity and requirement to bring forward a scheme to put surgeons who have a specialty relating to cosmetic surgery on to its specialist registers. With Amendment 293, we have the benefit of being able to do this by virtue of the recommendations in recent years from the Cosmetic Surgery Interspecialty Committee of the Royal College of Surgeons. It gives us an opportunity to give those who wish to undertake surgical treatments for cosmetic purposes the opportunity to see who is on the specialist register. All this relates to the safety of those undertaking cosmetic treatments, which is a large number of people; there is a large amount of activity and a significant need for the consumers of these services to have a degree of protection. I think we can make progress on that.

In the rest of this group, we have another opportunity to take action. My noble friend was right when she spoke about a more general approach. She will recall that, in April 2014, the Law Commission produced its recommendations on the regulation of healthcare professionals, so there is an opportunity to do something here. If we do not do it in this Bill, it would not hurt for the Government to tell us more about how they might make progress on the broader regulation, in addition to what is being proposed here.

I want to mention two other things. First, we had an earlier debate about access to innovative medicines. This is another opportunity for my noble friend to tell the Committee that NHS England is proceeding with its consultation on the implementation of the innovative medicines fund. Secondly, we do not need to repeat the short debate we had in Grand Committee not so very long ago under the auspices of my noble and learned friend Lord Mackay of Clashfern, who enabled us to present a lot of arguments about the future of NHS Resolution and clinical negligence within the NHS. We do not need to repeat that, but Amendments 178 and 297E would of course help us in that direction, not least by repealing the redundant NHS Redress Act 2006, which has never been implemented. With that thought, I pass the ball to the noble Lord, Lord Storey.

Photo of Lord Bethell Lord Bethell Conservative

My Lords, I support Amendment 266 in the name of the noble Baroness, Lady Merron, and Amendment 293 in the name of my noble friend Lord Lansley for all the reasons that my noble friend just articulated. I will not repeat them as he put them so very well. However, I would say to the Minister that, coming from the innovation space, I can see that the technologies for both cosmetic surgery and non-surgical cosmetic interventions are improving all the time. There is an incredibly rapid pace of change. They are set to continue to get better and better, so the marketplace is getting more sophisticated and their popularity is also exploding. We have been briefed on evidence about the role of social media in promoting non-surgical cosmetic interventions in particular. This is exciting, because it is great that people have access to these interesting products, but also extremely worrying, because not all the surgeries and non-surgical interventions are successful. It is the right time for the Government to intervene, so that we have a register of cosmetic surgical practitioners and a much clearer regulatory regime for non-surgical interventions.

I am pro cosmetic surgery. As a young boy, I had an inherited condition of having very big, sticking-out ears, which my father had and my cousins and aunts have, and it was miserable. I had them pinned back and I am very grateful that that happened. It meant that I could be a much more confident person as I grew up. I am pro cosmetic interventions; if people want to use the benefits of medicine to improve their confidence in the way they look, I applaud that. However, standing next to my noble friend Lady Cumberlege, I am also aware of Bruce Keogh’s extremely good report and the very large number of interventions that have not gone well. I know that the Minister’s instincts are not to intervene unless absolutely required and my suggestion to him is that we have hit that moment. The marketplace is exploding and now is the right time to intervene.

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Deputy Chairman of Committees, Deputy Speaker (Lords)

My Lords, as I address Amendment 266, I should declare that I am a vice-president of the Chartered Institute of Environmental Health. I stress that this amendment has been supported by the Beauty Industry Group, which represents 10 industry organisations—two voluntary registers for cosmetic practitioners, the Mental Health Foundation and others.

There are currently significant gaps in our regulatory system. Environmental health and licensing professionals work at a local authority level. They inspect, register and license premises for a very limited set of procedures, such as acupuncture, tattoos and piercing. Even for these procedures, however, there are no nationally set training programmes or qualification requirements for somebody to practise. For the riskier beauty procedures, such as the injectables, there are only voluntary registers of accredited practitioners. They have some approved education and training but that is not mandatory.

That means that there are many unaccredited practitioners on the high street providing services to people directly with no checks. A licensing scheme, as outlined in the amendment, would provide appropriate qualification and competency standards for practitioners wishing to practise, which is key to improving safety. The amendment as drafted is an open power for the Secretary of State, so it is easily amended as new procedures come online and on to the marketplace. The weakness of existing legislation in the area is that it fails to cover many of the newer treatments that are now popular.

When things go wrong, it is the NHS that has to pick up the pieces. Infections, injuries, scarring, burns and allergic reactions from a range of procedures often all end up in the NHS, sometimes with people being hospitalised and disfigured. Injection of fillers—or botulinum toxins—into blood vessels can cause dying back of tissues as well as blindness when administered by people who really are not adequately trained and certainly not registered. That means that there is no recompense for people damaged by these practitioners, who have no medical insurance or qualifications. In addition, there are unauthorised advertisements that breach advertising standards. There are strict laws around prescription-only medicines such as botulinum toxin, but these advertisements seem to bypass those.

Among members of the public who have had cosmetic procedures, alarmingly, three-quarters were given no information about the product, volume, brand or batch number of whatever was being used and just under three-quarters were not asked anything at all about their psychosocial or mental health or any body image issues. It is a vast and complex area and there are gaps in regulations. We need a national framework of standards with qualifications that can be recognised, so that there is a clear badge for members of the public.

To briefly address Amendment 297, I suggest that it is not needed because dermatological surgery and plastic surgery are subsections of medical practice and already registered with the General Medical Council. This gets nearer to credentialling than to requiring a separate qualification. These are doctors. They are highly trained, they have gone through a recognised training programme and they have been often examined as part of their exit from their training in whatever procedure they are undertaking.

I remind the Committee that, in a recent letter from the right honourable Michael Gove, he said that he is considering a licensing scheme. I hope the Government will see that this amendment would allow such a scheme without tying the Government down, and I hope that they will accept it, as well as Amendment 264 from the noble Lord, Lord Hunt, for which I should declare that I am an honorary fellow of the of the Royal College of Physicians of Edinburgh and the Royal College of Emergency Medicine. I think the contents of the amendment would go wider than simply surgical procedures. The Royal College of Emergency Medicine was established as a separate medical college in 2008, but the guidance and regulations were written prior to that, so they are completely out of date for what is now emerging as a major specialty across medicine. That amendment would rectify a lacuna.

The last amendment I want to speak to is Amendment 242, so clearly introduced by the noble Baroness, Lady Fraser. We need clear and transparent criteria for deciding which professions are regulated, and how the Government use their powers and the principles behind the criteria. Amendment 242 would provide such criteria. As we have discussed in the context of a previous Bill on domestic abuse, titles such as “therapist”, “psychotherapist” and “counsellor” are not protected. Courses in these subjects are unregulated, their quality varies widely and they are not registered anywhere. Charlatan practitioners can wreak havoc on people’s lives. The public have no idea that these people are not registered or regulated in any way. Even if serious concerns are expressed or complaints raised about them, they remain immune from investigation through the channels by which the health professions are regulated. I urge the Minister to look at that carefully.

Linked to this is the proposal that the title “nurse” should be protected, and I, for one, strongly support that. There is confusion in the mind of the public, and I recall one charitable sector provider that put all nurses and care assistants in the same uniform. That meant that patients and relatives were completely confused as to who was a trained nurse and who was a care assistant. They had no idea about what staff could and could not do and how much information they could give. Fortunately, the uniforms were changed fairly quickly. The public have a right to know that they are being looked after by a highly qualified, very skilled person—and that is a nurse.

Photo of Lord Borwick Lord Borwick Conservative 5:00 pm, 26th January 2022

Briefly, I support Amendment 176 from the noble Lord, Lord Hunt. I first declare two interests as a patron of thyroid charities, particularly the Thyroid Trust, whose leader, Mrs Lorraine Williams, has done great work on behalf of patients. I should also declare that I once suffered from Graves’ disease, with an unpredictably hyperactive thyroid gland. This may have been one of the few parts of my body that was hyperactive, but it was surgically removed and, ever since, I have taken daily levothyroxine. However, some patients cannot take levothyroxine but need liothyronine instead. It is a shame that some patients have been unable to get that drug when they need it so badly. I know that the NHS must control total drug costs, but the history of its control of that particular drug has perhaps not been perfect. The fault is originally that of the manufacturer, not the NHS, but it is patients who have suffered. The amendment of the noble Lord, Lord Hunt, would solve this problem.

Photo of Lord Sharkey Lord Sharkey Liberal Democrat

My Lord’s, I shall speak to Amendments 178 and 240, and I remind the Committee of my interest as chair of the Specialised Healthcare Alliance.

Amendment 178 deals with innovative medicines and medicinal products. The debate on this amendment is very timely, given the recent conclusion of NICE’s review of its methods and processes and the current consultation on the innovative medicines fund. Both the review and the IMF consultation are to be welcomed. It is clear that they will result in improvements in the system of assessing medicines and medicinal products, particularly in respect of analysing and addressing uncertainty and incorporating more real-world evidence into decision-making. However, it is also clear that both the IMF proposals and the outcome of NICE’s review are at risk of falling short of the hopes of many patients, clinicians and the life sciences sector more generally in a number of important ways.

First, there is still a lacuna in NICE’s approach to considering treatments for rare disease. For ultra-rare diseases—those affecting fewer than 1,000 people—NICE retains its highly specialised technologies process. For more common conditions—those affecting more than 25,000 people—NICE has its separate technology appraisal process. But for patients with rare diseases—those affecting between 1,000 and 25,000 people—there is no process, and so treatments for these patients have to be considered instead through the unsuitable technology appraisal process. This gap sets us apart from other countries, such as the more generous ASMR system in France and the AMNOG system in Germany for evaluating rare disease treatments.

It was therefore very disappointing to see that the case for the rare disease modifier was again rejected in NICE’s review. It was rejected on the grounds that society does not value treatments for rare disease more highly than those for more common diseases. Those representing rare-disease patients would contend that the fact is that these treatments are inherently costly. The Government accept this in relation to ultra-rare disease, so why do they not do so for rare disease treatments? I would be grateful if the Minister could address that specific question when he replies.

Secondly, NICE’s own consultation looked favourably on reducing the discount rate at which NICE assesses the future costs and benefits offered by a treatment, saying that such a change

“could make a particularly big difference to some treatments, like gene therapies.”

However, NICE has now said that this change would not be possible, due to the views of “system stakeholders”, and this has disappointed many people. When the Minister replies, I would be grateful if he could expand on what “system stakeholders” really means in this context. Who is NICE talking about and why did it assign conclusive weight to their views?

Thirdly, the system in England still fails to formalise the input of patients and clinical experts in the way that, for example, the SMC in Scotland does through its patient and clinical engagement process.

Finally, proposals for the innovative medicines fund now move far beyond the originally planned narrow focus on autoimmune and rare diseases. This causes some SHCA members to worry that rare diseases will get less attention than originally envisaged.

These proposals fall short of the hoped for bridge between the MHRA’s licensing process—which reforms are speeding up in some cases—and NICE’s reimbursement process. Without such a bridge, earlier licensing will not deliver benefits to NHS patients, and ultimately companies will lose interest in making bespoke licensing applications to the MHRA. The Government’s own figures—the life sciences competitiveness indicators, published by the Office for Life Sciences—demonstrate that it is already the case that the per capita uptake of new medicines remains lower and slower in this country than in comparable countries.

Our Amendment 178 suggests that the Government review the situation by the end of the year, when we will have a good half year of experience of the changes to NICE and the operation of the IMF, and when we will be able to see that the hoped for improvements have materialised. I hope that the Minister will consider this suggestion.

I now turn to Amendment 240, which seeks to probe the Government’s actions to improve awareness of rare diseases among healthcare professionals. There are more than 7,000 rare diseases, and it would clearly be impossible for every healthcare professional to receive training on every single one of them. However, as the Government’s rare disease framework notes, healthcare professionals can improve their awareness of rare diseases more generally, be more alert to considering them and be provided with the educational resources that help them recognise rare diseases in patients. Healthcare professionals can also be better supported to help signpost patients with rare disease to information about their condition and to help them understand it.

In a 2016 survey by Rare Disease UK, it was found that 70% of patients were not provided with sufficient information on their condition following diagnosis, and that 35% of patients given information did not understand the information that they were given.

More recent surveys demonstrated that these challenges continue. The Government’s national conversation on rare diseases in 2019 found that almost one in five people living with a rare condition reported that a lack of healthcare professional awareness of their disease was the number one challenge that they faced, and healthcare professionals themselves identified it as the second biggest challenge they faced behind only the well-known difficulties in obtaining an accurate diagnosis. I accept that healthcare professional regulators can do only so much to make improvements, but it would be helpful to understand from the Minister what steps they might be able to take to help better embed rare disease content in training frameworks.

Finally, there is a wider question of how the Government currently track progress in increasing awareness of rare diseases among healthcare professionals. How do the Government do that? I look forward to the Minister’s reply.

Photo of Baroness Meyer Baroness Meyer Conservative

My Lords, in speaking to Amendment 266, I shall not speak for long because everything has been said. The noble Baroness, Lady Finlay of Llandaff, explained the problem very clearly as did other speakers.

The only reason I want to speak is that in April last year I spoke in favour of the Private Member’s Bill introduced to this House by my noble friend Lady Wyld which sought to prevent cosmetic procedures being performed in England on people aged under 18 unless under the direction of a medical practitioner. The Bill was passed with cross-party and government support. As a result, children are now better protected. It is high time that we protected the population at large. When one hears of all the side-effects and that people can buy a product online and inject it into themselves or somebody else, it feels like the wild west, and the consequences can be quite dramatic, as we have heard. I very much hope that the Government will be able to support this amendment. This is not complicated and needs to be done quickly.

Photo of Baroness Pitkeathley Baroness Pitkeathley Deputy Chairman of Committees, Deputy Speaker (Lords)

I want to follow the noble Lord, Lord Sharkey, because I am former chair of the Specialised Healthcare Alliance. I shall speak very briefly in support of Amendments 164 and 178 in his name and that of my noble friend Lady Wheeler.

Every reorganisation of the NHS leaves patients who have a rare or less common condition anxious about how their particular needs will be assessed, how they will be met and even how they will be noted. It is sadly true that the rarer or more specialised a condition, the more it comes down to a postcode lottery whether the patient will be able to access care in spite of established national standards. Not only is it harder to access care, it is also harder for these patients to access the support groups or information networks which are vital when finding out the sometimes rare information about these conditions. The suggestion in Amendment 164 that the CQC assess the provision by ICBs of care for those with rare or less common conditions would provide the assurance that is so badly need.

Photo of Baroness Bennett of Manor Castle Baroness Bennett of Manor Castle Green

My Lords, in part because I listened to the lecture with which we started this session but more because it is an old anecdote, I shall forbear from telling my hospital food horror story. However, I will pick up on the points made by the noble Lord, Lord Hunt, and the noble Baroness, Lady Barker, about hospital food and how hard people are trying to improve the situation. This relates to the answer the Minister gave me on Monday in Oral Questions. Of course, it is dependent on the budget that caterers have and the quality of the food that is available to them. I was pleased that the Minister then said that the Government are looking to tackle government procurement to improve the quality of vegetables and fruit. In terms of joining up the dots, that is a useful point to make.

On Amendment 243, I offer the Green group’s support and note that, having been in your Lordships’ House for only a little more than two years, I have debated a very similar amendment at least once before—I think it must have been on the Medicines and Medical Devices Bill. We have all seen briefings that are very much a cry from the heart from the nursing profession for this to happen. Surely we can get this into this Bill.

I mainly want to address Amendments 266 and 293 in the name of the noble Lord, Lord Lansley, to which I have attached my name. While I take the point of the noble Lord, Lord Bethell, that these procedures can be crucial to people’s well-being and enable them to feel more comfortable in their skin, I want to briefly address where these amendments have arrived from. A headline from the Sunday Times two weeks ago said that

“TikTok and Instagram have fuelled demand for nose jobs, butt lifts and boob implants”.

I was a sub-editor on the Times 20 years ago. Quite aside from thinking “What is the world coming to?” when I read that headline, it is important to stress how much pressure there is from social media, particularly on young people, to have these surgical and non-surgical procedures.

It is important to acknowledge that it is not just young people who are affected. We live in an extremely ageist society, and many older people, despite our shortage of labour in many areas, can find it difficult to get jobs, or at least jobs that fit with their qualifications. A survey from the American Aesthetic Surgery Journal found that 30% of people sought surgery after they had suffered discrimination. Ministry of Justice figures show that in 2020 there were 3,668 complaints about age discrimination at employment tribunals, and that was up from 2,112 in 2019. I am aware we are likely to hear from the Minister, “These amendments may be heading in the right direction, but we need more time. There are issues to think about before we do anything.” It is crucial to get action now on surgical and non-surgical issues.

Finally, last July’s report from the APPG on Beauty, Aesthetics and Wellbeing addressed the absence of regulation, and this particularly relates to Amendment 266. Picking up on the point from the noble Baroness, Lady Finlay, the report also called for mandatory psychological screenings to be implemented.

I would love to hear the Minister say “Yes, go ahead”, because there is a demand here for urgent action.

Photo of Baroness Watkins of Tavistock Baroness Watkins of Tavistock Deputy Chairman of Committees 5:15 pm, 26th January 2022

My Lords, I apologise to the Committee for omitting to say that I am a registered nurse on the NMC database. I think this is important in relation to Amendment 243.

Photo of Baroness Walmsley Baroness Walmsley Co-Deputy Leader of the Liberal Democrat Peers

My Lords, I will be as brief as I can. I have a few words about some of the amendments in this wide-ranging group.

Amendment 243 would protect the title “nurse”. I know from family members that the qualification of registered nurse is always hard won, the result of very hard work. It involves rigorous basic training, often followed by further training in a specialty such as mental health nursing or surgery. The title provides a high level of trust among patients and the general population, because we know that a nurse must be registered with the Nursing and Midwifery Council, or a different responsible body for dental or veterinary nurses. There should therefore be clarity about who can use the title, and it could be sorted out very simply by the Minister—I hope he will do it.

A further anomaly, which the Minister can easily sort out in his reply, is that of the appointment of surgeons. I hope he will remove that anomaly as well.

I commend the work of my noble friend Lord Sharkey on rare diseases. I will not repeat what he said about what is needed, but I hope the Minister can give him some assurance.

I strongly support Amendment 266 on the need for a register for those who practise aesthetic non-surgical interventions. I will not repeat what my noble friend Lady Brinton and others have said about the reasons for this.

Amendment 293 requires a special register for cosmetic surgery. It is important that we have an up-to-date, comprehensive and rigorous method of assessing and registering the qualifications of surgeons safely to carry out cosmetic surgery. The question is: how is that done? I have received a briefing from the GMC, which tells me that it does not support the creation of a separate register for cosmetic surgery practitioners. Instead, the GMC believes that its proposal to move to a single GMC register that includes all doctors, anaesthesia associates and physician associates, and special annotation with work to develop relevant credentials, will provide additional assurance beyond that which could be provided by a separate additional register.

We are told that something better is coming down the track and that the forthcoming regulatory reform programme is intended to rationalise and streamline registration across all the UK healthcare regulators, and will allow the GMC to deliver an accessible, flexible and discretionary registration framework for all registrant groups. That is why the GMC believes that that will provide greater flexibility to develop and amend registration rules and improve its ability to innovate. Given the rapid development of new spheres of medicine and practices, such flexibility could be advantageous.

I understand that the GMC is now developing credentials with royal colleges and health education bodies, and that the first group of those is led by one on cosmetic surgery, plus four other disciplines. So, while I heartily agree with the intention of Amendment 293, I ask the Minister: when will the regulatory reform mentioned in the GMC briefing be completed? When will Parliament be able to see it and, in the meantime, how can we be assured that the current system gives the assurance on patient safety that is required?

I too support the noble Lord, Lord Hunt, on hospital catering and I too will resist giving my anecdote.

Photo of Lord Kamall Lord Kamall The Parliamentary Under-Secretary for Health and Social Care

I thank noble Lords for their contributions and for sharing their knowledge and expertise—and, in the case of hospital food, not sharing their tales of inadequate and unhealthy food. I will try to answer as many of the questions as possible but, given the experience of the noble Lord, Lord Patel, of being advised by a nurse Whip, I am keen to make sure that I do not suffer those same warnings, as it were.

On rare diseases, specifying requirements in the way proposed by the amendment would restrict the ability of the CQC to collaboratively develop its assessments of integrated care systems. However, the Government are committed to improving the lives of people living with rare diseases. The noble Lord, Lord Sharkey, rightly talked about the UK Rare Diseases Framework that we published in January 2021, which set out our key priorities for tackling rare diseases. England’s action plan will be published at the end of next month.

I have had conversations with some in the life sciences industry who are keen on the fact that we are focusing on rare diseases and extremely rare diseases, and see that as a positive. One of the things that we are trying to do across government is to make sure that we are seen as a hub for expertise in rare diseases and especially rare diseases. One of my predecessors as a Minister suffered from a rare disease. The momentum is still there in the department to make sure that we tackle the issue.

Also, the CQC, through its ICS assessment methodology, will seek to understand how system leaders are monitoring and meeting the needs of the local population, including those with rare diseases. We expect the CQC, in collaboration with system partners, to use its experience as the independent regulator of health and adult social care in England to develop an approach to those reviews. I know that noble Lords may be tired of hearing this but it is important that the legislation allows the CQC flexibility to do so.

On Amendment 240, while the Government have sympathy with the need to raise awareness, we do not consider it appropriate to put such a requirement into primary legislation. I hope I have reassured the noble Lord about our programmes and our push to raise the profile of rare diseases and extremely rare diseases. We prefer that all healthcare professional regulators require professionals to have the necessary skills and knowledge to practise safely, including awareness of rare conditions. It is the responsibility of the regulators to determine what specific role they should play in raising awareness of rare and less common conditions.

On—and I apologise if I mispronounce this—liothyronine and the power of direction, the NICE guideline on the assessment and management of thyroid disease, as the noble Lord acknowledged, does not recommend liothyronine for primary hypothyroidism. NICE states that there is not yet enough evidence that it offers benefits over levothyroxine monotherapy, and its long-term adverse effects are uncertain. If new evidence was to emerge, I am sure NICE would consider it.

In addition, we must be careful not to override NICE guidelines. But, given the concerns raised by the noble Lord, Lord Hunt, and my noble friend Lord Borwick, I would like a further conversation, if that is okay, to see what can be done in this area, as well as where it is appropriate for me to act and what conversations would be appropriate, given the noble Lord’s experience as a Health Minister.

On Amendment 178, we are committed to further strengthening the innovation metrics and to improving our understanding of how innovative medicines and these products are used in the NHS. Noble Lords will be aware that following the publication of the final report of the Accelerated Access Review, the Government established the Accelerated Access Collaborative—AAC—last year. In fact, last year alone we helped over 300,000 patients access proven innovations, resulting in 17,000 fewer hospital admissions and 140,000 fewer days spent in hospital.

As noble Lords are aware, we published our ambitious Life Sciences Vision, which laid out our priorities. We want to make sure that the NHS is seen as a partner in innovation and that research is embedded into everything the NHS does. I know that this has been raised in relation to other amendments. We are currently developing implementation plans for delivering on these commitments.

As noble Lords acknowledged, NICE is in the final stages of the review of its methods and processes, and is proposing a number of changes that will introduce real benefits to patients, including rare disease patients. The Government are also committed to developing an innovative medicines fund, which my noble friend referred to, and a consultation on detailed proposals for the fund closes on 11 February.

Finally, our rare disease framework outlines the key priorities for rare diseases in the UK over the next five years. One priority area is to improve access to specialist care, treatments and drugs.

On hospital food, although we recognise the expertise and declarations of the noble Lords who spoke, we believe that this amendment is unnecessary because the issues are already covered, either as part of the ongoing work to implement recommendations from the hospital food review or in the NHS food standards document, to be published in spring 2022.

The Government are supporting NHS England to implement the recommendations from the independent review. These recommendations cover a broad range of issues, including nutrition, hydration, healthier eating and sustainable procurement. It is important for me to learn more about this as a Minister, given what the noble Baroness, Lady Barker, said about many people not receiving the recognition they deserve. It would be appropriate, perhaps, for us to meet and follow this up.

In addition, the Government already have sufficient legal powers and obligations to enable them to consult on proposed food standards, and we have engaged with NHS trusts, the food standards and strategy group, and the NHS food review expert group through the NHS food review. We will continue to do all this.

On Amendment 264, the regulations already allow trusts to seek alternative members to contribute to the process. They can be from colleges such as the Royal College of Surgeons of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Emergency Medicine. However, the Government agree that the changes proposed by noble Lords in Amendment 264 would potentially be advantageous —to put it that way—and we have undertaken to review the situation with officials.

The National Health Service Act 2006 stipulates that consultation with affected parties must be undertaken before any changes are made. Therefore, before we jump to it and agree, we are required to consult the relevant parties. It does seem a clear-cut case, but we are still under a duty to consult.

Turning to Amendment 266, I thank the noble Baroness, Lady Merron, for the meeting yesterday. Interestingly, we kicked around some of the issues and realised that this is not as simple as it might appear: where do you draw the line? The Government are committed to improving the safety of cosmetic procedures and ensuring that the regulatory framework allows consumers to make informed but safe choices. Patient safety must always come first. A number of noble Lords referred to the Private Member’s Bill from my noble friend Lady Wyld, which we were pleased to support for these reasons. The department wants to work with stakeholders to take this work forward in the most appropriate way, and we commend the work of the All-Party Parliamentary Group on Beauty, Aesthetics and Wellbeing in this area.

However, we must look at where you draw the line. When I have looked at studies from, for example, the United States, on structural racism and getting people from poorer backgrounds into work and them becoming entrepreneurs, an issue often raised is whether occupational licences are a barrier to people. In some states, you require a licence to braid hair. Where do we draw the line? Clearly, where there is a safety concern and where chemicals are used, but that is probably a more straightforward case. We have to make sure that it is not a barrier to people getting to work and is seen as part of structural racism.

On Amendment 293, I thank my noble friend Lord Lansley and others for mentioning the work commissioned from Sir Bruce Keogh. As many noble Lords will know, doctors who practice cosmetic surgery are regulated by the General Medical Council. I take the point made by the noble Baronesses, Lady Walmsley and Lady Finlay. I repeat that, to strengthen assurance, the GMC, in conjunction with the Royal College of Surgeons, is developing a cosmetic surgery credential. GMC-approved credentials formally recognise doctors’ expertise in specific areas of practice. The credential will aim to enhance regulation and patient protection by recognising surgeons who have the appropriate training qualifications. I do not have the exact deadlines here yet, but I can find out and write to noble Lords, probably in my write-around.

On Amendment 242, our proposed reforms will introduce a new duty on regulators to collaborate with one another and key stakeholders when making changes to how they regulate. There are many factors that we need to consider when bringing forward legislation, but the fundamental consideration must always be public protection. The professions protected in law need to be the right ones, and the level of regulatory oversight must be proportionate to the risks to the public.

The noble Baroness, Lady Wheeler, asked about the review of professional regulators. We have commissioned KPMG to carry out an independent review of the regulatory landscape. It submitted its report at the end of last year, and the findings are now being considered. Any use of the powers provided for in Clause 142 will be subject to consultation and the approval of both Houses.

To respond to my noble friend Lady Fraser, we are committed to bringing forward a programme to reform the legislative framework and professional regulators across the UK. There are various strands to the reform programme, and we are making progress. We have received over 500 responses to the consultation and officials are analysing them. We hope to bring forward legislation on the issue this year.

Given all that, and given the public consultation and other issues, I ask noble Lords to withdraw and not press their amendments.

Photo of Lord Patel Lord Patel Crossbench 5:30 pm, 26th January 2022

My Lords, the Minister suggested that, to have any changes in the appointment of surgeons, the department would have to consult first. I assume that the only body it would need to consult is the Royal College of Surgeons, which I understand is sympathetic to the change. If that is the case, it is a simple matter, so can it not be consulted before Report?

Photo of Lord Kamall Lord Kamall The Parliamentary Under-Secretary for Health and Social Care

If it is as straightforward as the noble Lord suggests, I will see if that can be done.

Photo of Baroness Wheeler Baroness Wheeler Shadow Spokesperson (Health and Social Care), Opposition Deputy Chief Whip (Lords), Shadow Spokesperson (Levelling Up, Housing, Communities and Local Government)

My Lords, I thank noble Lords for their many expert and very informative contributions. It has been a fascinating debate on a number of issues.

On specialised care services and rare diseases, I note the Minister’s comments and thank him for some of his reassurances, but there were some issues that he did not cover, particularly in relation to my noble friend’s Amendment 178. However, I welcome the dialogue that is taking place on these issues, and the recognition of their complexity, and am very hopeful that that will continue. We will take stock to see if anything else needs to come back on Report. I also thank my noble friend Lady Pitkeathley for her support on this issue.

In the general debate, noble Lords will, I am sure, follow up on the points that they made, as the noble Lord, Lord Patel, just did. I thought the contributions of my noble friend Lord Hunt and the noble Baroness, Lady Barker, on the hospital food situation, really drove home the importance of this issue. We must make progress on it and move forward.

On the title “nurse”, strong support was expected and we certainly got it from across the House. I hope that progress can be made. The issue will not go away, as the Minister knows, and neither will the determination of my noble friend Lord Hunt to pursue the issue of the availability of T3 for thyroid patients. We hope that progress can be made on that, because again it is a situation that a must be addressed.

The noble Baronesses, Lady Masham and Lady Brinton, and other noble Lords made valuable points on the vital need for a licensing regime for non-surgical cosmetic procedures, again underlining the need for urgent, step-by-step progress, and demonstrating in particular why the current situation is unacceptable. Progress can be made. As the noble Lord, Lord Lansley, pointed out, it was seen in the recent Private Members’ Bill on Botox fillers. We need progress to be made, and steadily.

Finally, on the reference to when the review of the regulatory system will be completed—the noble Baroness, Lady Walmsley, also raised this—the issue was about timescales. We know there is a review. We are told that KPMG is on the case and has delivered its report, but we need timescales and action as soon as possible.

With those comments, I beg leave to withdraw my amendment.

Amendment 164 withdrawn.

Amendment 164A not moved.

Clauses 26 and 27 agreed.